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Home > Library > WOUND & SKIN CARE: Calling on NERDS for critically colonized wounds |
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SUPPOSE YOUR 74-year-old patient has an open wound that won't heal (see photo), although you've followed best practice wound care guidelines. The wound hasn't changed size in 3 weeks, is bright red, and has increasing amounts of exudate. You also notice yellowish-brown slough in the right lateral aspect and a slightly sweet odor that you hadn't noticed before. This is the time to call on NERDS to help determine if the wound is critically colonized. But before we discuss the NERDS assessment tool, let's evaluate what's happening in this wound. What's a critically colonized wound?
A critically colonized wound lacks clinical signs of infection, despite supporting a bacteria level close to the maximum level the host can tolerate. Critical colonization is one stage along the bacterial balance continuum, which consists of: * sterility—absence of bacteria
* colonization—also called contamination. Bacteria are in the wound but aren't causing tissue damage or delaying healing.1
* critical colonization—microbes in the wound are growing faster than they're dying, delaying healing 1
* infection—bacteria in the wound have spread to surrounding tissue and deeper tissues, causing damage and triggering an inflammatory response. I'll discuss infected wounds and how to manage them in a future article.
Ineffective host defenses seem to be the precipitating factor that moves a wound from one stage to the next.2 Host defenses include an adequate vascular supply, effective immune system, absence of chronic disease, and adequate nutrition. These all encourage wound healing and lessen the likelihood of infection.  Figure. A wound that doesn't heal may be critically colonized, calling for special treatment. Help from NERDS
The mnemonic NERDS can help you remember the characteristics that suggest a critically colonized wound.2 Manytypical signs and symptoms of wound infection, such as pain, increased wound temperature, new areas of breakdown, and frank wound deterioration, are absent, so this memory aid can help you make an accurate assessment. N onhealing wound—this may be the only clue that the wound is critically colonized. Normal healing is a decrease in wound size of 20% to 40% in 4 weeks.1 E xudative wound—serous exudate is common. R ed and bleeding wound—some critically colonized wounds are a pale, pearly gray. Normal granulation tissue is pink and firm. D ebris—visible in the wound. This necrotic tissue should be debrided to encourage healing. S mell or odor—emanates from the wound. Make sure you don't confuse the smell of tissue necrosis caused by bacteria with the smell of exudate mixing with a wound dressing. In essence, the critically colonized stage is the calm before the storm. By recognizing trouble now, you can initiate appropriate treatment before the balance is tipped further and deeper tissue infection occurs. What's appropriate treatment?
Most experts recommend topical treatments to prevent the microorganisms from invading deeper tissues.1–3 Deeper tissue involvement generally requires systemic management.2 Antimicrobial dressings containing silver or cadexomer iodine are available as topical treatments. A vast array of silver products is available, so choose a dressing that best suits the wound characteristics.3 For example, if the wound has profuse exudate, a hydrofiber with silver or a foam dressing with silver may be the best choice. (A hydrofiber dressing combines moist wound healing with the look, feel, and handling properties of gauze and alginates.) For a wound that has a foul odor as well as toxins from Gram-negative bacteria, charcoal/silver combination dressings may be effective. Drier wounds with necrotic tissue may benefit from a silver-based gel. Using the best possible dressing is key to avoiding tissue toxicity and possible bacterial resistance.2 The cause of the patient's colonization also should be identified and corrected if possible. Maintain the patient's nutritional status and monitor any coexisting disorders. Once bacterial balance is achieved, discontinue the use of topical antimicrobials and initiate moist wound healing if the area has an adequate vascular supply. (Patients who are at high risk for infection—for example, patients with severely weakened immune systems—may need topical antimicrobials for a longer period.2 ) Reassess the wound frequently, following your facility's protocol. A 20% to 40% reduction in wound size after 2 to 4 weeks indicates wound healing.4 If the wound doesn't start to heal and shows signs of deterioration and deeper tissue involvement despite topical antimicrobial treatment, notify the health care provider and start systemic antimicrobial therapy as prescribed.5 Helping your patient
Let's return to the hypothetical patient at the beginning of this article. You apply a silver-based hydrofiber and a foam dressing which are changed every 2 days. In 3 weeks, you document a 25% reduction in wound size, no slough, and less friability (or easy bleeding), indicating that bacterial balance was achieved. By assessing the wound correctly and initiating early interventions, you helped prevent a potentially serious wound infection. REFERENCES
1. White RJ, et al. Wound colonization and infection: The role of topical antimicrobials. British Journal of Nursing . 10(9):563–579, May 2001. [Context Link] 2. Sibbald RG, et al. Increased bacterial burden and infection: The story of NERDS and STONES. Advances in Skin & Wound Care. 19(8):447–461, October 2006. [Context Link] 3. Krasner D. Dressing decisions for the 21st century: On the cusp of a paradigm shift. In Krasner D, Kane D. (eds) Chronic Wound Care: A Clinical Source Book for Healthcare Professionals, 2nd edition. Wayne, Pa., Health Management Publications, Inc., 1997. [Context Link] 4. Flanagan M. Wound measurement: Can it help us to monitor progression to healing? Journal of Wound Care. 12(5):189–194, May 2003. [Context Link] 5. Sibbald RG, et al. Preparing the wound bed 2003: Focus on infection and inflammation. Ostomy/Wound Management. 49(11):24–51, November 2003. [Context Link] |
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